Healthcare Provider Details

I. General information

NPI: 1619941879
Provider Name (Legal Business Name): JERRY LANE LOWDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FOREST PARK AVE DIV OBGYN PELVIC MED/RECONSTRUCT SURG, STE 710
SAINT LOUIS MO
63108-1495
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-1402
  • Fax: 314-362-3328
Mailing address:
  • Phone: 314-747-1402
  • Fax: 314-362-3328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2013044288
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number2013044288
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: